Provider Demographics
NPI:1356327522
Name:BERRY, ROBERT G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:BERRY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 S MCCARRAN BLVD
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6135
Mailing Address - Country:US
Mailing Address - Phone:775-828-2873
Mailing Address - Fax:775-828-2889
Practice Address - Street 1:6630 S MCCARRAN BLVD
Practice Address - Street 2:SUITE A-4
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6135
Practice Address - Country:US
Practice Address - Phone:775-828-2873
Practice Address - Fax:775-828-2889
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6668208100000X, 208VP0000X
CAG75770208100000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016504Medicaid
NV11039746OtherCAQH
NV11039746OtherCAQH
NV002016504Medicaid